Navigator-Driven Remote Optimization of Guideline-Directed Medical Therapy in Patients with Heart Failure with Reduced Ejection Fraction: Program Design and Initial feasibility

摘要

IntroductionAlthough optimal pharmacological therapy for heart failure with reduced ejection fraction (HFrEF) is carefully scripted by treatment guidelines, many eligible patients are not treated with guideline-directed medical therapy (GDMT) in clinical practice. We designed a strategy for remote optimization of GDMT on a population scale in patients with HFrEF leveraging non-physician providers. A navigator-led remote medication optimization program will enhance implementation of GDMT in HFrEF patients. MethodsAn electronic health record-based algorithm was used to identify a cohort of patients with a diagnosis of HF and EF ≤ 40% receiving longitudinal follow up at our center. Those with end-stage HF requiring inotropic support, mechanical circulatory support, or transplantation and those enrolled in hospice or palliative care were excluded. Treating providers were approached for consent to adjust medical therapy according to a sequential, stepped titration algorithm modelled on the current ACC/AHA HF Guidelines. A navigator then facilitated medication adjustments by telephone and conducted longitudinal surveillance of laboratories, blood pressure, and symptoms. Each titration step was reviewed by a pharmacist under supervision of a nurse practitioner and HF cardiologist. Patients were discharged from the program to their primary cardiologist after achievement of an optimal or maximally tolerated regimen. (Figure). ResultsTo date, 615 HFrEF patients have been initially screened for eligibility, of whom 197 (32%) were deemed suitable for remote medication optimization. Further chart review determined 11 (6%) of these patients were already optimized by guidelines. Cardiologists for the remaining 186 patients were approached; provider consent was received for 145 patients (78%). Of these 145 patients, 13 (9%) declined participation, 13 (9%) were unreachable by telephone, and the remaining 119 have been enrolled. ConclusionA navigator-led remote management strategy for optimization of GDMT is feasible for a large proportion of patients with HFrEF and appears acceptable to the vast majority of patients and providers. This approach may represent a scalable population-level strategy for closing the gap between guidelines and clinical practice in patients with HFrEF.